Section 2: Presenting Situation

Background Questionnaire

Confidential: For Report Purposes Only

Thank you for filling out the following questionnaire. Please click "Submit" at the end of each section. (Note: You will not be able to save your progress, so please complete each section fully before submitting.)

Know that this information is very important to the assessment, so please be comprehensive and provide as much detail as possible.

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Section 2: Presenting Situation

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Child's name *

First

Last

Today's Date *

Form completed by (include relationship to child) *

Who referred you for an evaluation? *

What is this person's professional role / relationship to you? *

Why did this person refer you for an evaluation? *

List your primary concerns about your child. *

When did you first notice these difficulties? *

What information would you like this assessment to provide? What questions do you hope to have answered by this evaluation? *

Please describe your child's strengths. *

What are your child's favorite activities? *

What activities would your child like to engage in more than at present? *

What activities does your child like the least? *

If you would like to qualify any responses or add additional notes, please do so here. After you click "submit," you will be redirected to the For Clients page. *

Submit